NURS344 Health Assessment Exam 3

A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing a. Enuresis b. stress incontinence c. urinary frequency d. urge continence

b. stress incontinence

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? a. Air conduction is the normal pathway for hearing b. Vibrations of the bones in the skull cause air conduction c. Amplitude of sound determines the pitch that it is heard d. Loss of air conduction is called a conductive hearing loss

a. Air conduction is the normal pathway for hearing

The nurse is performing an assessment on a 7-year-old who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices that the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: a. Allergies b. Sinus infection c. Nasal congestion d. Upper respiratory infection

a. Allergies

The nurse is completing a focused head and neck assessment of a client admitted with tension headache. What questions would the nurse ask the client? SELECT ALL THAT APPLY a. "Have you have any recent job changes or anxiety?" b. "Could you describe the pain you are feeling to me?" c. "Are you sure you feeling that pain?" d. "Could you indicate where the pain you are feeling is located?"

a. "Have you have any recent job changes or anxiety?" b. "Could you describe the pain you are feeling to me?"

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurses's most appropriate response to this would be: a. "I would like some more information about the pain in your left breast" b."Don't worry about the pain, breast cancer is not painful" c. "Breast pain is almost always the result of benign breast disease" d. "Oh, I had pain like that after my son was born; it turned about to be a blocked milk duct"

a. "I would like some more information about the pain in your left breast"

During the interview, a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurses most appropriate response to this would be: a. "Oh, don't worry. Some cyclic vaginal discharge is normal" b. "Have you been engaging in unprotected sexual intercourse?" c."I'd like some information about the discharge. What color is it?" d. "Have you had any urinary incontinence associated with the discharge?"

c."I'd like some information about the discharge. What color is it?"

During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is the: a. Cochlea b. CN VIII c. Organ of Corti d. Labyrinth

d. Labyrinth

A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is a. Just above the diaphragm b. Just lateral to the knee cap c. At the level of the C7 veterbra d. At the level of the T11 vertebra

C. At the level of the C7 vertebra

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: a. Acquired immunodeficiency syndrome (AIDS) b. Measles c. Leukemia d. Carcinoma

a. Acquired immunodeficiency syndrome (AIDS)

The uterus is usually positioned titling forward and superior to the bladder. This position is known as: a. Anteverted and anteflexed b. Retroverted and anteflexed c. Retroverted and retroflexed d. Superiorverted and anteflexed

a. Anteverted and anteflexed

The nurse assesses a male client's genitalia and finds that the scrotal contents are asymmetrical. What action does the nurse take? a. Ask the client about any usual genital observations b. Insert an indwelling urinary catheter to ensure urine flow c. Request a prostate-specific antigen diagnostic blood test d. Call the health care provider and request diagnostic testing

a. Ask the client about any usual genital observations The nurse must first be aware of any pre-existing conditions the patient may have that may cause the abnormal finding. Unless there are other symptoms, there is no reason to jump any steps.

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurses next response should be to: a. Ask the patient to lock her fingers and pull b. Complete the examination, and then test these reflexes again c. Refer the patient to a specialist for further testing d. Document these reflexes as 0 on a scale of 0-4+

a. Ask the patient to lock her fingers and pull Documenting the reflexes as absent is inappropriate this soon. The nurse should try to encourage relaxation, varying the person position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested

A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father died of prostate cancer. The nurse knows which tests should be performed at this time? SELECT ALL THAT APPLY a. Blood test for prostate-specific antigen (PSA) b. Urinalysis c. Transrectal ultrasound d. Digital rectal examination (DRE) f. Prostate biopsy

a. Blood test for prostate-specific d. Digital rectal examination (DRE)

A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for "a couple of minutes"; then he is able to resume his activities. What does these symptoms suggest? a. Claudication b. Sore muscles c. Muscle cramps d. Venous insufficiency

a. Claudication

During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should: a. Continue the examination because a bruit is a normal finding for this age b. Check for the bruit again in 1 hour c. Notify the parents that a bruit has been detected in their child d. Stop the examination, and notify the physician.

a. Continue the examination because a bruit is a normal finding for this age

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? a. Denver II b. Sterognosis c. Deep tendon reflexes d. Rapid alternating movements

a. Denver II

During an ophthalmoscopic examination of the eye, the nurse notices areas of exudate that appears similar to cotton wool or fluffy clouds. The nurse recognized that the patient may have: a. Diabetes b. Hyperthyroidism c. Glaucoma d. Hypotension

a. Diabetes

When examining the patient's eyes, the nurse notices that his eyelid margins approximate completely when closed. The nurse will: a. Document this as a normal finding b. Evaluate the extraocular muscles c. Refer the patient for problems with tearing d. Assess for increased intraocular pressure

a. Document this as a normal finding

When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: a. Ear dysplasia b. Long, thin neck c. Protruding thin tongue d. Narrow and raised nasal bridge

a. Ear dysplasia

The nurse is preparing to palpate the rectum and should use which of these techniques? The nurse should: a. Flex the finger, and slowly insert it toward the umbilicus b. First instruct the patient that this procedure will be painful c. Insert an extended index finger at a right angle to the anus d. Place the finger directly into the anus to overcome the tight sphincter

a. Flex the finger, and slowly insert it toward the umbilicus

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c. Local inflammation d. Blockage of lymphatic drainage

a. Heart failure

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? a. High-tone frequency loss b. Increased elasticity of the pinna c. Thin, translucent membrane d. Shiny, pink tympanic membrane

a. High-tone frequency loss

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

a. Hyperreflexia

A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient has: a. Impaired vision b. Exophthalmos c. Normal visions d. Presbyopia

a. Impaired vision

A patient states that the pain medication is "not working" and rates his postoperative pain at a 10. on a 1-10 scale. Which of the assessment findings indicates an acute pain response to poorly controlled pain? a. Increased blood pressure and pulse b. Confusion c. Hyperventilation d. Depression

a. Increased blood pressure and pulse

The gerontologic nurse is inspecting the genitalia of an older adult female client. Which assessment findings are of the most concern? SELECT ALL THAT APPLY a. Increased size of the labia unilaterally b. Smooth skin and slightly drier mucosa c. Darker pigmentation to vulva d. Scant red vaginal discharge e. Decreased amount of pubic hair

a. Increased size of the labia unilaterally d. Scant red vaginal discharge

The nurse is going to perform an assessment of a male client's genitalia. Which order is the most appropriate for conducting a male genitalia assessment? a. Inspect external genitalia, palpate scrotum, and inspect inguinal area b. Inspect external genitalia and then palpate scrotum and inguinal area c. Only inspect the external genitalia and then palpate the scrotum d. Inspect overall genitalia and then inspect the inguinal area only.

a. Inspect external genitalia, palpate scrotum, and inspect inguinal area

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? SELECT ALL THAT APPLY a. Intense, sharp pain, with the deep muscle tender to the touch b. Aching, tired pain, with a feeling of fullness c. Pain that is worse at the end of the day d. Sudden onset e. Warm, red, and swollen calf f. Pain that is relieved by elevation of the leg

a. Intense, sharp pain, with the deep muscle tender to the touch d. Sudden onset e. Warm, red, and swollen calf

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart b. The high-pressure system of the heart helps to facilitate venous return c. Contracting skeletal muscles milk blood distally toward the veins d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart

a. Intraluminal valves ensure unidirectional flow toward the heart

The nurse is caring for a client who is being admitted to the intensive care unit with bilateral pulmonary emboli. The client is reporting anxiety and apprehension. Would would the nurse do? SELECT ALL THAT APPLY a. Modify procedures as much as possible to limit stress b. Tell the client about a friend who had the same situation c. Note cultural influences that may influence individual response d. Encourage client to express and acknowledge feelings e. Assure the client that it will be alright after the treatment

a. Modify procedures as much as possible to limit stress c. Note cultural influences that may influence individual response d. Encourage client to express and acknowledge feelings

The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? SELECT ALL THAT APPLY a. Nontender mass b. Dull, heavy pain on palpation c. Rubbery texture and mobile d. Hard, dense, and immobile e. Regular border f. Irregular, poorly delineated border

a. Nontender mass d. Hard. dense, and immobile f. Irregular, poorly delineated border

A nurse is caring for a client who has a right femur fracture that is currently in traction. The client has a prescription for hourly circulatory assessment. Which nursing assessment findings should be reporting to the health care provider? SELECT ALL THAT APPLY a. Numbness and tingling to the right leg b. Pedal pulses +2 bilaterally c. Pink color and warmth to bilateral legs d. Edema and coolness to the right calf e. Right capillary refill of 4 seconds

a. Numbness and tingling to the right leg d. Edema and coolness to the right calf e. Right capillary refill of 4 seconds

The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is: a. On the same day every month b. Daily, during the shower or bath c. One week after her menstrual period d. Every year with her annual gynecologic examination

a. On the same day every month

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is: a. Otosclerosis b. Presbycusis c. Trauma to the bones d. Frequent ear infections

a. Otosclerosis

The nurse is palpating a client's precordium. Which is an expected clinical finding? a. Palpable pulsation over the mitral area b. Palpable thrill over the aortic area c. Palpable vibration over the right sternal border d. Palpable heave over the pulmonic area

a. Palpable pulsation over the mitral area

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? SELECT ALL THAT APPLY a. Patient has a history of diabetes and cigarette smoking b. Skin of the patient is pale and cool c. His ankles have two small, weeping ulcers d. Patient works long hours sitting at a computer desk e. He states that the pain gets worse when walking f. Patient states that the pain is worse at the end of the day

a. Patient has a history of diabetes and cigarette smoking b. Skin of the patient is pale and cool e. He states that the pain gets worse when walking

When assessing a patient's cardiovascular system, the nurse notes a high pitched scratchy sound at the apex of the heart. The nurse recognizes this as rubbing between the two walls of the sac surrounding and protecting the heart, called the: a. Pericardium b. Myocardium c. Endocardium d. Pleural space

a. Pericardium

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease? a. Person who has been on bed rest for 4 days b. Older adult taking anticoagulant medication c. Woman in the second month of her pregnancy d. Person with a 30-year, 1 pack per day smoking habit

a. Person who has been on bed rest for 4 days

A nurse is inspecting the external genitalia of a female client. Which assessment finding is of the most concern? a. Pink labia lesions b. Coarse brown hair c. Dark pink vulva d. Whitish vaginal discharge

a. Pink labia lesions

A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition? a. Prostatitis b. Polyps c. Carcinoma of the prostate d. BPH

a. Prostatitis

When testing a patient's visual accommodation, the nurse notes a normal finding when the patient demonstrates: a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light

a. Pupillary constriction when looking at a near object

The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body? a. Radiation b. Exercise c. Food digestion d. Metabolism

a. Radiation

When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. Based on this observation, the nurse should: a. Recognize that a tripod position is often used when a patient is having respiratory difficulties b. Assume that the patient is eager and interested in participating in the interview c. Assume that the patient is having difficulty breathing and assist him in a supine position d. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position

a. Recognize that a tripod position is often used when a patient is having respiratory difficulties

The nurse is assessing an older adults advanced activities of daily living (AADLs), which would include: a. Recreational activities b. Meal preparation c. Balancing the checkbook d. Self-grooming activities

a. Recreational activities

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

a. Reflexes will be normal.

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? a. Skin of the patient is pale and cool b. His ankles have two small, weeping ulcers c. He states that the pain gets worse when walking d. Patient works long hours sitting at a computer desk e. Patient has a history of diabetes and cigarette smoking f. Patient states that the pain is worse at the end of the day

a. Skin of the patient is pale and cool c. He states that the pain gets worse when walking e. Patient has a history of diabetes and cigarette smoking

When examining a patients CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a. Sternomastoid and trapezius b. Spinal accessory and omohyoid c. Trapezius and sternomandibular d. Sternomandibular and spinal accessory

a. Sternomastoid and trapezius

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? SELECT ALL THAT APPLY a. Sudden onset b. Warm, red, and swollen calf c. Pain that is worse at the end of the day d. Aching, tired pain, with a feeling of fullness e. Pain that is relieved with elevation of the leg f. Intense, sharp pain, with the deep muscle tender to the touch

a. Sudden onset b. Warm, red, and swollen calf f. Intense, sharp pain, with the deep muscle tender to the touch

A 16-year-old boy is brought to the clinic for a problem that he refused to let his mother see. The nurse examines him, and finds that he has scrotal swelling on the left side. He had the mumps the previous week, and the nurse suspects that he has orchitis. Which of the following assessment findings support this diagnosis? SELECT ALL THAT APPLY a. Swollen testis b. Mass that transilluminates c. Mass that does not transilluminate d. Scrotum that is nontender upon palpation e. Scrotum that is tender upon palpation f. Scrotal skin that is reddened

a. Swollen testis c. Mass that does not transilluminate e. Scrotum that is tender upon palpation f. Scrotal skin that is reddened

The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patients T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Tachycardia b. Constipation c. Rapid dyspnea d. Atrophied nodule thyroid gland

a. Tachycardia

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging b. These findings could be related to hyperthyroidism c. These findings are the result of Parkinson disease d. The patient should be evaluated for a cerebellar lesion

a. These findings are normal, resulting from aging

A patients laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _______ gland a. Thyroid b. Parotid c. Adrenal d. Parathyroid

a. Thyroid

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare two sides b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between ones thumb and forefinger, and then move down the neck muscle d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

a. Using gentle pressure, palpate with both hands to compare two sides

The nurse is reviewing the changes that occur with menopause. Which changes are associated with menopause? a. Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium b. Ovarian atrophy, increased vaginal secretions, and increasing clitoral size c. Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions d. Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine hypertrophy

a. Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium

During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as: a. Vertigo b. Syncope c. Dizziness d. Seizure Activity

a. Vertigo

The nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination a. Woman whose nipples are in different planes (deviated) b. Women whose left breast is slightly larger than her right c. Nonpregnant woman who skin is marked with linear striae d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin

a. Woman whose nipples are in different planes (deviated)

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hand that affects his ability to hold things. With this information, what response should the nurse make? a. "Does your family know you're drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor"

b. "Does the tremor change when you drink alcohol?"

The nurse is teaching a review class on the lymphatic system. Which statement by a class participant indicates correct understanding of the material? a. "Lymph flow is propelled by the contraction of the heart" b. "The flow of lymph is slow, compared with that of blood" c. "One of the functions of the lymph is to absorb lipids from the biliary tract" d. "Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream"

b. "The flow of lymph is slow, compared with that of blood"

The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? a. Ask the patient to assume a prone position b. Ask the patient to bend his or her knees to the side in a froglike position c. The nurse firmly presses against the bone with the patient in a semi-Fowler position d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult

b. Ask the patient to bend his or her knees to the side in a froglike position

A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mmHg and a heart rate of 90 bpm. The nurse hears an extra heart sound at the apex immediately before S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n): a. Split S1 b. Atrial gallop c. Diastolic murmur d. Summation sound

b. Atrial gallop

During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: a. Valvular disorder b. Blood flow turbulence c. Fluid volume overload d. Ventricular hypertrophy

b. Blood flow turbulence

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. When assessing this patient's pulse, what should the nurse expect? a. Normal b. Bounding c. Weak, thready d. Unpalpable pedal pulse

b. Bounding

During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? SELECT ALL THAT APPLY a. Chronic alcohol use b. Cigarette smoking c. Frequent episodes of strep throat d. Chronic allergies e. Aging f. Herpes simplex virus

b. Cigarette smoking d. Chronic allergies e. Aging

A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a. Hypertension b. Cluster headaches c. Tension headaches d. Migraine headaches

b. Cluster headaches

After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): a. Annual proctoscopy b. Colonoscopy every 10 years c. Fecal test for blood every 6 months d. DREs every 2 years

b. Colonoscopy every 10 years

After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): a. Annual proctoscopy b. Colonoscopy every 10 years c. Fecal test for blood every 6 months d. Digital rectal examination every 2 years

b. Colonoscopy every 10 years

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" The nurse responds by telling the patient that the middle ear functions to: a. Interpret sounds as they enter the ear b. Conduct vibrations of sounds to the inner ear c. Maintain balance d. Increase amplitude of sound for the inner ear to function

b. Conduct vibrations of sounds to the inner ear

The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia b. Corticospinal tract c. Spinothalamic tract d. Extrapyramidal tract

b. Corticospinal tract corticospinal fibers mediate voluntary movements. AKA the pyramidal tract, is a newer and higher motor system that permits very skilled and purposeful movements.

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a. Bells palsy b. Damage to the trigeminal nerve c. Frostbite with resultant paresthesia to the cheeks d. Scleroderma

b. Damage to the trigeminal nerve

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Mental retardation d. Increased intracranial pressure

b. Dehydration

a 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying, "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? SELECT ALL THAT APPLY a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in ones own neighborhood

b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in ones own neighborhood

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? a. Hard and fixed cervical nodes b. Enlarged and tender inguinal nodes c. Bilateral enlargement of the popliteal nodes d. Pelletlike nodes in the supraclavicular region

b. Enlarged and tender inguinal nodes

The nurse is conducting a focused musculoskeletal and peripheral vascular assessment on a client. What should the nurse do first? a. Measure capillary refill b. Examine range of motion c. Check for peripheral edema d. Assess the peripheral pulses

b. Examine range of motion

The telemetry nurse is conducting an initial cardiac assessment on a client admitted with chest pain and coronary artery disease (CAD). What should the nurse do first? a. Auscultate the heart for murmurs at Erb's point b. Examine the client's chest for any visible pulsations c. Palpate the left chest for the apical impulse d. Rolle the client onto the left side to assess heart sounds

b. Examine the client's chest for any visible pulsations

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? a. Examine the tender area first b. Examine the tender area last c. Avoid palpating the tender area d. Palpate the tender area first, and then auscultate for bowel sounds

b. Examine the tender area last

The nurse is palpating a female patient adnexa. The findings include a firm, smooth uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. The nurses most appropriate course of action would be to: a. Tell the patient that her examination is normal b. Give her an immediate referral to a gynecologist c. Suggest that she return in a month for a recheck to verify the findings d. Tell the patient that she may have an ovarian cyst that should be evaluated further

b. Give her an immediate referral to a gynecologist

The nurse is assessing a 1-month-old infant has his well-baby check up. Which asssessment findings are appropriate for this age? SELECT ALL THAT APPLY a. Head circumference equal to chest circumference b. Head circumference greater than chest circumference c. Head circumference less than chest circumference d. Fontanels firm and slightly concave e. Absent tonic neck reflex f. Nonpalpable cervical lymph nodes

b. Head circumference greater than chest circumference d. Fontanels firm and slightly concave f. Nonpalpable cervical lymph nodes

A mother brings her newborn in for an assessment and asks "Is there something wrong with my baby? His head seems so big." Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length b. Head circumference should be greater than the chest circumference at birth c. The head reaches 90% of its final size when the child is 3 years old d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

b. Head circumference should be greater than the chest circumference at birth

A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: a. Chalazion b. Hordeolum (stye) c. Dacryocystitis d. Blepharitis

b. Hordeolum (stye)

An older patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which instrument is most appropriate for the nurse to choose at this time? a. Lawton IADL instrument b. Hospital Admission Risk Profile (HARP) c. Mini-cog d. NEECHAM Confusion Scale

b. Hospital Admission Risk Profile (HARP)

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye indicating the presence of: a. Hypopyon b. Hyphema c. Corneal abrasion d. Pterygium

b. Hyphema AKA another term for blood in the anterior chamber and is a serious result of blunt trauma or spontaneous hemorrhage

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? a. Red and bulging b. Hypomobility c. Retraction with landmarks clearly visible d. Flat, slightly pulled in at the center, and moves with insufflation

b. Hypomobility As pressure increases, the tympanic membrane begins to bulge.

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mmHg; heart rate 104 bpm and slightly irregular; and split S2. Which of these findings is an expected hemodynamic change related to age? a. Increase in resting heart rate b. Increase in systolic blood pressure c. Decrease in diastolic blood pressure d. Increase in diastolic blood pressure

b. Increase in systolic blood pressure

The nurse is conducting the initial thorax and lung assessment of a client with pneumonia. What would the nurse do first? a. Auscultate the anterior, lateral, and posterior thorax with the stethoscope. b. Inspect the skin, bones, and muscles of the entire posterior thorax c. Palpate using the dorsal surface of the hands over the posterior thorax d. Assess the anteroposterior (AP) and lateral diameters of the thorax

b. Inspect the skin, bones, and muscles of the entire posterior thorax

The nurse knows that normal splitting of S2 is associated with: a. Expiration b. Inspiration c. Exercise rate d. Low resting heart rate

b. Inspiration

If a patient reports a recent breast infection, then the nurse should expect to find ___________ node enlargement a. Nonspecific b. Ipsilateral axillary c. Contralateral axillary d. Inguinal and cervical

b. Ipsilateral axillary

A 31-year-old patients tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: a. Is normal for people his age b. Is a characteristic of recruitment c. May indicate a middle ear infection d. Indicates that the patient has a cerumen impaction

b. Is a characteristic of recruitment

A patient says that she has recently noticed a lump in the front of her neck below her Adams apple that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule in that the lump (nodule): a. Is tender b. Is mobile and not hard c. Disappears when the patient smiles d. Is hard and fixed to the surrounding structures

b. Is mobile and not hard

The nurse is reviewing age-related changes of the eye for a class. Which os these physiological changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decrease adaptation to darkness d. Decreased distance vision abilities

b. Loss of lens elasticity

The nurse is performing a morning assessment on the medical-surgical unit. Which clients are most likely to have palpable lymph nodes in the neck? SELECT ALL THAT APPLY a. Man, 75, who is severely dehydrated b. Man, 67, with aspiration pneumonia c. Woman, 69, with congestive heart failure d. Woman, 62, with chronic bronchitis

b. Man, 67, with aspiration pneumonia d. Woman, 62, with chronic bronchitis

During the neurologic assessment of a health 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some direction of movement

b. Mild, even resistance to movement

The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass characteristics would suggest the presence of an ovarian cyst? SELECT ALL THAT APPLY a. Heavy and solid b. Mobile and fluctuant c. Mobile and solid d. Fixed e. Smooth and round f. Poorly defined

b. Mobile and fluctuant e. Smooth and round

During the assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

b. Motor component of CN VII

The nurse has just completed an inspection of a nulliparous womans external genitalia. Which of these would be a description of a finding within normal limits? a. Redness of the labia majora b. Multiple nontender sebaceous cysts c. Discharge that is foul smelling and irritating d. Gaping and slightly shriveled labia majora

b. Multiple nontender sebaceous cysts

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: a. Shotty b. Nonpalpable c. Large, firm, and fixed to tissue d. Rubbery, discrete, and mobile

b. Nonpalpable

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. When interpreting these findings, what should the nurse expect? a. Alterations in arterial function will cause edema b. Nonpitting, hard edema occurs with lymphatic obstuction c. Phlebitis of a superficial vein will cause bilateral edema d. Long-standing arterial obstruction will cause pitting edema

b. Nonpitting, hard edema occurs with lymphatic obstuction

The nurse is performing the diagnostic positions test and notes normal findings with: a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Lid lag when moving the eyes from a superior to an inferior position

b. Parallel movement of both eyes

A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that needs to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a. Thyroid gland b. Parotid gland c. Occipital lymph node d. Submental lymph node

b. Parotid gland

A 65-year-old patient is experiencing pain in his left calf when he exercises which disappears after resting for a few minutes. What problem in the left leg does this indicate? a. Venous obstruction b. Partial blockage of an artery c. Claudication due to venous abnormalities d. Ischemia caused by complete blockage of an artery

b. Partial blockage of an artery

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assess for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? SELECT ALL THAT APPLY a. Patient may experience sensitivity to light, nausea, and holes around lights b. Patient experiences tunnel vision in the late stages c. Immediate treatment is needed. d. Vision loss begins with peripheral vision e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision f. Virtually no symptoms are exhibited

b. Patient experiences tunnel vision in the late stages d. Vision loss begins with peripheral vision f. Virtually no symptoms are exhibited

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: a. Diarrhea b. Peritonitis c. Laxative use d. Gastroenteritis

b. Peritonitis

Then nurse knows that testing kinesthesia is a test of a persons: a. Fine touch b. Position sense c. Motor coordination d. Perception of vibration

b. Position sense

The nurse is assessing the abilities of an older adult. Which activities are considered IADLs? SELECT ALL THAT APPLY a. Feeding oneself b. Preparing a meal c. Balancing a checkbook d. Walking e. Toileting f. Grocery shopping

b. Preparing a meal c. Balancing a checkbook f. Grocery shopping

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? SELECT ALL THAT APPLY a. Hearing loss related to aging begins in the mid 40s b. Progression of hearing loss is slow c. The aging person has low-frequency tone loss d. The aging person may find it harder to hear consonants than vowels e. Sounds may be garbled and difficult to localize f. Hearing loss reflects nerve degeneration of the middle ear

b. Progression of hearing loss is slow d. The aging person may find it harder to hear consonants than vowels e. Sounds may be garbled and difficult to localize

The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patients trachea is: a. Pulled to the affected side b. Pulled to the unaffected side c. Pulled downward d. Pulled downward in a rhythmic pattern

b. Pulled to the unaffected side

The nurse is assessing the abdomen of a pregnant woman who is complaining of having acid indigestion all the time. The nurse knows that esophageal reflux during pregnancy can cause: a. Diarrhea b. Pyrosis c. Dysphagia d. Constipation

b. Pyrosis

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worreid because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: a. Loss of central vision b. Shadow or diminished vision in one quadrant or one-half of the visual field c. Loss of peripheral vision d. Sudden loss of pupillary constriction and accommodation

b. Shadow or diminished vision in one quadrant or one-half of the visual field

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? a. Quickly palpate a tender area to avoid any discomfort that the patient may experience b. Start with light palpation to detect surface characteristics and to accustom the patient to being touched. c. Avoid palpation of reported "tender " areas because this may cause the patient pain d. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths

b. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? a. Low humming sound b. Swishing, whooshing sound c. Regular "lub", "dub" pattern d. Steady, even, flowing sound

b. Swishing, whooshing sound

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? SELECT ALL THAT APPLY a. Test for the Murphy sign b. Test for the Blumberg sign c. Test for shifting dullness d. Perform the iliopsoas muscle test e. Test for fluid wave

b. Test for the Blumberg sign d. Perform the iliopsoas muscle test

The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? a. The nurse uses direct observation to implement this tool b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability c. This instrument is not useful in the acute hospital setting d. This tool is best used for those residing in an institutional setting.

b. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability

The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? a. The rectum is approximately 8 cm long b. The anorectal junction cannot be palpated c. Above the anal canal, the rectum turns anteriorly d. No sensory nerves are in the anal canal or rectum

b. The anorectal junction cannot be palpated

The nurse is conducing a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reverse from its actual appearance in the outside world c. Light rays are refracted through the transparent media of the eye before striking the pupil d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain

b. The image formed on the retina is upside down and reverse from its actual appearance in the outside world

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding? a. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working. b. The jugular veins will remain elevated as long as pressure on the abdomen is maintained. c. An impulse will be visible at the fourth or fifth intercostal space at or inside the MCL. d. The jugular veins will not be detected during this maneuver

b. The jugular veins will remain elevated as long as pressure on the abdomen is maintained.

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: a. The largest quadrant of the chest b. The location of most breast tumors c. Where most of the suspensory ligaments attach d. More prone to injury and calcification than other locations in the breast

b. The location of most breast tumors

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one very sharp prick. What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process b. This response is most likely the result of the summation effect c. The nurse was probably not poking hard enough with the pin in the other areas d. The patient most likely has analgesia in some areas of his arm and hyperalgesia in others

b. This response is most likely the result of the summation effect

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b. Tongue that looks smoother in appearance c. Buccal mucosa that is beefy red in appearance d. Small, painless lump on the dorsum of the tongue

b. Tongue that looks smoother in appearance

During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area b. Tympanic percussion note in the umbilical region c. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line d. Dull percussion note in the left upper quadrant at the midclavicular line

b. Tympanic percussion note in the umbilical region

The nurse is performing an eye assessment on an 80-year-old patient and is concerned that the finding has: a. Decreased tear production b. Unequal pupillary constriction in response to light c. Arcus senilis around the cornea d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

b. Unequal pupillary constriction in response to light

During an examination the nurse observes a female patient's vestibule and expects to see the : a. Paraurethral (Skene) and vestibular (Bartholin) glands b. Urethral meatus and vaginal orifice c. Vaginal orifice and vestibular (Bartholin) glands d. Urethral meatus and paraurethral (Skene) glands

b. Urethral meatus and vaginal orifice

During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as: a. Uterine prolapse, graded first degree b. Uterine prolapse, graded second degree c. Uterine prolapse, graded third degree d. A normal finding

b. Uterine prolapse, graded second degree

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ____ and proceeds with the examination by _______ a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign

b. XI; asking the patient to shrug her shoulders against resistance

A mother asks when her newborn infant's eyesight will be fully developed. The nurse should reply: a. "Vision is not fully developed until 2 years of age." b. " Infants develop the ability to focus on an object at approximately 8 months of age." c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." d. "Most infants have uncoordinated eye movements for the first year of life."

c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object."

A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. "I'll be sleeping great, and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: a. "When was your last electrocardiography done?" b. "It's probably because it's been so hot at night." c. "Do you have an history of problems with your heart?" d. "Have you had a recent sinus infection or upper respiratory infection?"

c. "Do you have an history of problems with your heart?"

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" a. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning signs before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

c. "Do you have any warning signs before your seizure starts?"

While assessing a patient who is hospitalized and bedridden, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. The nurse recognizes that this finding indicated which of the following? a. Occult blood b. Inflammation c. Absent bile pigment d. Ingestion of iron preparations

c. Absent bile pigment

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurses finger, then his own nose, then the nurses finger again (which as been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoot the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy

c. Acute alcohol intoxication

The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain. Which statement about pain and the older adult is true? a. Pain is inevitable with aging b. Older adult with cognitive impairment feel less pain c. Alleviating pain should be a priority over other aspects of the assessment d. The assessment should take priority so that care decisions can be made

c. Alleviating pain should be a priority over other aspects of the assessment

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3 cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. Based on these findings, what does the nurse suspect? a. Varicosities b. Venous stasis ulcer c. Arterial ischemic ulcer d. Deep vein thrombophlebitis

c. Arterial ischemic ulcer

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: a. Check for the presence of exophthalmos b. Suspect that the patient has hyperhtyroidism c. Ask the patient if he or she has a history of heart failure d. Assess for belpharitis which is often associated with periorbital edema

c. Ask the patient if he or she has a history of heart failure

During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Immediately contact the physician to report the discharge b. Ask her is she is possibly pregnant c. Ask the patient some additional questions about the medications she is taking d. Immediately obtain a sample for culture and sensitivity testing.

c. Ask the patient some additional questions about the medications she is taking

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination reveals that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? a. Assessing the eye for a possible foreign body b. Documenting the finding as ptosis c. Assessing for other signs of ectropion d. Contacting the referring physician; these are signs of basal cell carcinoma.

c. Assessing for other signs of ectropion

The nurse needs to assess a patients ability to perform activities of daily living (ADLs) and should choose which tool for this assessment? a. Direct Assessment of Functional Abilities (DAFA) b. Lawton Instrumental Activities of Daily Living (IADL) scale c. Barthel Index d. Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire

c. Barthel Index

When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true? a. The left ventricle is larger and weighs more than the right ventricle b. The circulation of a newborn is identical to that of an adult c. Blood can flow into the left side of the heart through an opening in the atrial septum d. The foramen ovale closes just minutes before birth, and the ductus arteriosus closes immediately after

c. Blood can flow into the left side of the heart through an opening in the atrial septum

In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal b. Pectoral, lateral, anterior, and sternal c. Central, lateral, pectoral, and subscapular d. Lateral, pectoral, axillary, and suprascapular

c. Central, lateral, pectoral, and subscapular

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: a. Exopthalmos b. Bowed long bones c. Coarse facial features d. Acorn-shaped cranium

c. Coarse facial features

When listening to heart sounds, the nurse knows that S1: a. Is louder than S2 at the base of the heart b. Indicates the beginning of diastole c. Coincides with the carotid artery pulse d. Is caused by the closure of the semilunar valves

c. Coincides with the carotid artery pulse

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated based. The preliminary analysis in this situation is that this: a. Is most likely a benign sebaceous cyst b. Is most likely a keloid c. Could be a potential carcinoma, and the patient should be referred for a biopsy d. Is a tophus, which is common in the older adult and is a sign of gout

c. Could be a potential carcinoma, and the patient should be referred for a biopsy

During the precordial assessment on a patient who is 9 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the MCL. This finding would indicate: a. Right ventricular hypertrophy b Increased volume and size of the heart as a result of pregnancy c. Displacement of the heart from the elevation of the diaphragm d. Increased blood flow through the internal mammary artery

c. Displacement of the heart from the elevation of the diaphragm

The nurse assesses a female client's genitalia and notes the vulva appears darker than the surrounding area and a clear discharge is present. What action does the nurse take? a. Ask the client about any noticed changes to the genitalia b. Recommend that the health care provider assess the client c. Document the physical findings in the medical record d. Obtain a sample of the discharge for culture and sensitivity

c. Document the physical findings in the medical record

During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!" Based on these symptoms, the nurse suspects that the patient has which condition? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis

c. Duodenal ulcer

The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements. the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

c. Dysfunction of the cerebellum

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a. Epistaxis b. Rinorrhea c. Dysphagia d. Xerostomia

c. Dysphagia

When examining a patient's eye, the nurse uses eye drops to stimulate the sympathetic branch of the autonomic nervous system to: a. Cause pupillary constriction b. Adjust the eye for near vision c. Elevate the eyelid and dilate the pupil d. Cause contraction of the ciliary body.

c. Elevate the eyelid and dilate the pupil

During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate? a. The best time to examine your breasts is during ovulation b. Examine your breasts every month on the same day of the month c. Examine your breast shortly after your menstrual period each month d. The best time to examine your breasts is immediately before menstruation

c. Examine your breast shortly after your menstrual period each month

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a. Clumped b. Unilateral c. Firm but freely movable d. Firm but nontender

c. Firm but freely movable

The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: a. Gallbladder disease b. Overuse of laxatives c. Gastrointestinal bleeding d. Localized bleeding around the anus

c. Gastrointestinal bleeding

During a well-baby check up, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, then nurse also notices dilated scalp veins and downcast or setting sun eyes. The nurse suspects which condition? a. Craniotabes b. Microcephaly c. Hydrocephalus d. Caput succedaneum

c. Hydrocephalus

The nurse is performing a cardiac assessment of a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: a. Increased cardiac output b. Another MI c. Inflammation of the precordium d. Ventricular hypertrophy resulting from muscle damage

c. Inflammation of the precordium

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patients thyroid gland is slightly enlarged. No enlargement had been previously noticed. The nurse suspects that the patient: a. Has an iodine deficiency b. Is exhibiting early signs of goiter c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy d. Needs further testing for possible thyroid cancer

c. Is exhibiting a normal enlargement of the thyroid gland during pregnancy

While performing a well-child assessment on a 5-year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child: a. Has chronic allergies b. May have an infection c. Is exhibiting a normal finding for a well-child of this age d. Should be referred for additional evaluation

c. Is exhibiting a normal finding for a well-child of this age

A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of: a. Ovary infection b. Liver enlargement c. Kidney inflammation d. Spleen enlargement

c. Kidney inflammation

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory tract d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

c. Lateral spinothalamic tract, thalamus, and sensory tract

The nurse is caring for a patient who has just had neurosurgery. To assess for increase intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

c. Level of consciousness, motor function, pupillary response, and vital signs

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: a. Posterior epistaxis b. Frontal sinusitis c. Maxillary sinusitis d. Nasal polyps

c. Maxillary sinusitis Typically includes facial pain after upper respiratory infections

A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones

c. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin

A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: a. Cachexia b. Parkinson syndrome c. Myxedema d. Scleroderma

c. Myxedema AKA hypothyroidism and is a deficiency of the thyroid hormone.

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's best response? a. Talk with the patient about his intake of caffeine b. Perform ECG after the examination c. No further response is needed because sinus arrrhythmia can occur normally d. Refer the patient to a cardiologist for further testing

c. No further response is needed because sinus arrrhythmia can occur normally

While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are: a. Pulsations of the renal arteries b. Pulsations of the inferior vena cava c. Normal abdominal aortic pulsations d. Increased peristalsis from a bowel obstruction

c. Normal abdominal aortic pulsations

A mother brings in her newborn infant for an assessment and tells that nurse that she has noticed whenever her newborns head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that his reflex is: a. Abnormal and is called atonic neck reflex b. Normal and should disappear by the first year of life c. Normal and is called the tonic neck reflex, which should disappear between 3-4 months of age d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.

c. Normal and is called the tonic neck reflex, which should disappear between 3-4 months of age

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next? a. Make note of this finding for the report to the next shift b. Prepare to remove cerumen from the patient's ear c. Notify the patient's health care provider d. Irrigate the ear with rubbing alcohol

c. Notify the patient's health care provider

A 60-year-old man suspected ptosis of one eye is at the clinic for an eye examination. The nurse confirms ptosis by" a. Performing the confrontation test b. Assessing the patient's near vision c. Observing the distance between the palpebral fissures d. Performing the corneal light reflex, and looking for symmetry of the light reflex

c. Observing the distance between the palpebral fissures

When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ____________ and _____________ glands. a. Occipital; submental b. Parotid; jugulodigastric c. Parotid; submandibular d. Submandibular; occipital

c. Parotid; submandibular

While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: a. Dimpling b. Retraction c. Peau dorange d. Benign breast disease

c. Peau dorange Lymphatic obstruction produces edema. The skin has a pig-skin or orange-peel appearance, and this condition suggests cancer

During an assessment of an older adult, the nurse should expect to which finding as a normal physiologic change associated with the aging process? a. Hormonal changes causing vasodilation and a resulting drop in blood pressure b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the planter flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale of 0-4+

c. Plantar reflex present

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia b. Astereognosis c. Presence of dysdiadochokinesia d. Loss of kinesthesia

c. Presence of dysdiadochokinesia

When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for: a. Drainage from dacryocystitis b. Presence of conjunctivitis over the iris c. Presence of shadows, which may indicate glaucoma d. Scattered light reflex, which may be indicative of cataracts

c. Presence of shadows, which may indicate glaucoma

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the outer aspect of the right ankle. What do these findings suggest? a. Pain r/t lymphatic abnormalities b. Problems r/t venous insufficiency c. Problems r/t arterial insufficiency d. Pain r/t musculoskeletal abnormalities

c. Problems r/t arterial insufficiency

In a patient who has anisocoria, the nurse would expect to observe: a. Dilated pupils b. Excessive tearing c. Pupils of unequal size d. Uneven curvature of the lens

c. Pupils of unequal size

A patients thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a _________ sound that is head best with the _________ of the stethoscope a. Low gurgling; diaphragm b. Loud, whooshing, blowing; bell c. Soft, whooshing, pulsatile; bell d. High-pitches tinkling; diaphragm

c. Soft, whooshing, pulsatile; bell

During an examination, the nurse finds that a patients left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a. Crepitation b. Mastoiditis c. Temporal arteritis d. Bells palsy

c. Temporal arteritis

When assessing a male child for colour deficiency the nurse will: a. Check colour vision annually until age 18 years b. Ask the child to identify the colour of his or her clothing c. Test for colour vision once between the ages 4 and 8 years. d. Begin colour vision screening at the child's 2-year check up

c. Test for colour vision once between the ages 4 and 8 years.

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed b. The dermatome served by this nerve will no longer experience any sensation c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component

c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve

The nurse is examining a 35-year-old female patient. During the health history, the nurse notices that she has had two preterm pregnancies, and both babies were delivered vaginally. During the internal examination, the nurse observes that the cervical os is a horizontal slit with some healed lacerations and that the cervix has some nabothian cysts that are small, smooth, and yellow. In addition, the nurse notices that the cervical surface is granular and red, especially around the os. Finally, the nurse notices the presence of stringy, opaque, odorless secretions. Which of these findings are abnormal? a. Nabothian cysts are present b. The cervical os is a horizontal slit c. The cervical surface is granular and red d. Stringy and opaque secretions are present

c. The cervical surface is granular and red

Which of these statements is true regarding the penis? a. The penis is composed of two cylindrical columns of erectile tissue b. The prepuce is the fold of foreskin covering the shaft of the penis c. The corpus spongiosum expands into a cone of erectile tissue called the glans d. The urethral meatus is located on the ventral side of the penis

c. The corpus spongiosum expands into a cone of erectile tissue called the glans

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from: a. Behind with the nurses hands placed firmly around his neck b. The side with the nurses eyes averted toward the ceiling and thumbs on his neck c. The front with the nurses thumbs placed on either side of his trachea and is head tilted forward d. The front with the nurses thumbs placed on either side of his traches and his head tilted backwards

c. The front with the nurses thumbs placed on either side of his trachea and is head tilted forward

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation for why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere

Which of these statements describes the closure of the valves in a normal cardiac cycle? a. The aortic valve closes slightly before the tricuspid valve b. The pulmonic valve closes slightly before the aortic valve c. The tricuspid valve closes slightly later than the mitral valve d. Both the tricuspid and pulmonic valves close at the same time

c. The tricuspid valve closes slightly later than the mitral valve

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? a. To measure the rate of lymphatic drainage b. To evaluate the adequacy of capillary patency before venous blood draws c. To evaluate the adequacy of collateral circulation before cannulating the radial artery d. To evaluate venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

c. To evaluate the adequacy of collateral circulation before cannulating the radial artery

A 10 year old is at the clinic for a sore throat that has lasted 6 days. Which of these findings would be consistent with an acute infection? a. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa b. Tonsils 2+/1-4+ with small plugs of white debris c. Tonsils 3+/1-4+ with large white spots d. Tonsils 3+/1-4+ with pale coloring

c. Tonsils 3+/1-4+ with large white spots

During an assessment, the nurse notices that a patients umbilicus is enlarge and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition? a. Intra-abdominal bleeding b. Constipation c. Umbilical hernia d. Abdominal tumor

c. Umbilical hernia

The nurse notices that a patients palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. III b. V c. VII d. VIII

c. VII

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? a. I b. III c. VIII d. XI

c. VIII

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a. scleroderma b. Bell's palsy c. damage to the trigeminal nerve d. frostbite with resultant paraesthesia to the cheeks

c. damage to the trigeminal nerve

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for then nurse to include in the health history would be: a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you lose your first tooth?" d. "Have you noticed any dryness in your mouth?"

d. "Have you noticed any dryness in your mouth?"

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? a. "Do you ever notice ringing or crackling in your ears?" b. "When was the last time you had your hearing checked?" c. " Have you ever been told that you have any type of hearing loss?" d. "Is there any relationship between the ear pain and the discharge you mentioned?"

d. "Is there any relationship between the ear pain and the discharge you mentioned?"

The nurse reviews causes of increased intraocular pressure (IOP) with the patient using the following explanation: a. "The pressure results from the thickness of the lens." b. "The posterior chamber increases in pressure as it accommodates increased fluid." c. "Contraction of the ciliary body in response to the aqueous within the eye increases pressure." d. "The pressure results from the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber."

d. "The pressure results from the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber."

The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a. 37-year-old who is slightly overweight b. 42-year-old who has had ovarian cancer c. 45-year-old who has never been pregnant d. 65-year-old whose mother had breast cancer

d. 65-year-old whose mother had breast cancer

A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart that her cervix is softened and looks cyanotic. The nurse knows that the woman is exhibiting _________ sign and __________ sign. a. Tanner, Hegar b. Hegar, Goodell c. Chadwick, Hegar d. Goodell, Chadwick

d. Goodell, Chadwick

When the nurse is performing a genital examination on a male patient, which action is correct: a. Auscultating for the presence of a bruit over the scrotum b. Palpating for the vertical chain of lymph nodes along the groin, inferior to the inguinal ligament c. Palpating the inguinal canal only if a bulge is present in the inguinal region during inspection d. Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side

d. Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side

Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient who has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.

d. A patient who has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? a. Normal ABI indices are from 0.5-1.0 b. Normal ankle pressure is slightly lower than the brachial pressure c. The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes d. An ABI of 0.9-0.7 indicates the presence of peripheral vascular disease and mild claudication

d. An ABI of 0.9-0.7 indicates the presence of peripheral vascular disease and mild claudication

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. Then nurse would need to know additional information that includes which of these? a. Any changes in the ability to hear b. Any recent drainage from the ear c. Recent history of trauma to the ear d. Any prolonged exposure to extreme cold

d. Any prolonged exposure to extreme cold

The nurse notices that a patients submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patients: a. Infraclavicular area b. Supraclavicular area c. Area distal to the enlarged node d. Area proximal to the enlarged node

d. Area proximal to the enlarged node

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds d. Brownish discoloration to the skin in the lower leg

d. Brownish discoloration to the skin in the lower leg

A 32-year-old woman tells the nurse that she has noticed very sudden, jerky movements mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests a. Tics b. Athetosis c. Myoclonus d. Chorea

d. Chorea

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which time of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

d. Complete neurologic examination

Which of the following statements is true regarding the internal structures of the breast? The breast is: a. Composed mostly of milk ducts, known as lactiferous ducts b. Composed of glandular tissue, which supports the breast by attaching to the chest wall c. Mainly muscle and very little fibrous tissue d. Composed of fibrous, glandular, and adipose tissue

d. Composed of fibrous, glandular, and adipose tissue

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should: a. Document the presence of hepatomegaly b. Ask additional health history questions regarding his alcohol intake c. Describe the dullness as indicative of an enlarged liver, and refer him to a physician d. Consider this finding as normal, and proceed with the examination

d. Consider this finding as normal, and proceed with the examination

The nurse recognizes that a patient has a normal pupillary reflex when: a. The eyes converge to focus on the light b. Light is reflected at the same spot in both eyes c. The eye focuses the image in the centre of the pupil d. Constriction of both pupils in response to bright light

d. Constriction of both pupils in response to bright light

During ocular examinations, the nurse assesses the movement of the extraocular muscles by stimulating: a. Cranial nerves VII and VIII b. The ciliary body c. The corneal reflex d. Cranial nerves III, IV, and VI

d. Cranial nerves III, IV, and VI

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters b. Presume the patient has glaucoma and refer patient for further testing. c. Consider these to be abnormal findings and refer patient to an ophthalmologist d. Document the findings as common with patient age

d. Document the findings as common with patient age

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: a. Decreased fluid volume b. Increased cardiac output c. Narrowing of jugular veins d. Elevated pressure related to heart failure

d. Elevated pressure related to heart failure

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment a. Rhinorrhea b. Periorbital edema c. Pain over the maxillary sinuses d. Enlarged superficial cervical nodes

d. Enlarged superficial cervical nodes

During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests: a. A normal heart b. Systolic murmur c. Enlargement of the left ventricle d. Enlargement of the right ventricle

d. Enlargement of the right ventricle

A patient visits the clinic because he has recently notices that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: a. Cushing syndrome b. Parkinson disease c. Bells palsy d. Experienced a cerebrovascular accident (CVA) or stroke

d. Experienced a cerebrovascular accident (CVA) or stroke

The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a. Head, breasts, groin, and abdomen b. Arms, breasts, inguinal area, and legs c. Head and neck, arms, breasts, and axillae d. Head and neck, arms, inguinal area, and axillae

d. Head and neck, arms, inguinal area, and axillae

During a cardiac assessment of a 38-year-old patient in the hospital for "chest pain." The nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated 45 degrees, blood pressure 98/60 mmHg, heart rate 130 bpm, ankle edema, difficulty breathing when supine, and S3 on auscultation. Which of these conditions best explains the cause of these findings? a. Fluid overload b. Atrial septum defect c. MI d. Heart failure

d. Heart failure

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: a. Loud continual hum b. Peritoneal friction rub c. Hypoactive bowel sounds d. Hyperactive bowel sounds

d. Hyperactive bowel sounds

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes

d. Hyperactive reflexes

Papilledema is revealed during an ophthalmic examination which the nurse recognizes as indicating: a. Retinal detachment b. Diabetic retinopathy c. Acute-angle glaucoma d. Increased intraocular pressure

d. Increased intraocular pressure

The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination, the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is in supine. These findings are most consistent with a(n) __________ hernia a. Scrotal b. Femoral c. Direct inguinal d. Indirect inguinal

d. Indirect inguinal

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with planter flexion. Which statement concerning these findings is most accurate? This patients response: a. Indicates a lesion of a cerebral cortex d. Indicates a completely nonfunctional brainstem c. Is normal and will go away in 24 to 48 hours d. Is a very ominous sign and may indicate brainstem injury

d. Is a very ominous sign and may indicate brainstem injury

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth d. Maxillary and ethmoid are the only sinuses present at birth

d. Maxillary and ethmoid are the only sinuses present at birth

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence d. May indicate disease of the cerebellum or brainstem c. Is a sign that the patient is nervous about the examination d. Indicates a visual problem, and a referral to an ophthalmologist is indicated

d. May indicate disease of the cerebellum or brainstem

A 19-year-old college student is brought to the emergency department with a severe headache that he describes as, "Like nothing I've ever felt before." His temperature is 40 degrees Celsius and he as a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation

d. Meningeal inflammation

A patient complains that while studying for an exam he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: a. Hypertension b. Cluster headaches c. Tension headaches d. Migraine headaches

d. Migraine headaches

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact. The patient: a. Demonstrate the ability to hear normal conversation b. Sticks out the tongue midline without tremors or deviation c. Follows an object with his or her eyes without nystagmus or strabismus d. Moves the head and shoulders against resistance with equal strength

d. Moves the head and shoulders against resistance with equal strength

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: a. Pulsations of the inferior vena cava b. Increased peristalsis from a bowel obstruction c. Pulsations of the renal arteries d. Normal abdominal aortic pulsations

d. Normal abdominal aortic pulsations

The nurse is caring for a client who was recently admitted to the cardiac care unit after open-heart surgery. The current assessment by the nurse reveals +0 pedal pulse on the left foot and +2 pedal pulse on the right foot. What should the nurse do first? a. Elevate the client's right leg to increase the circulation b. Reassess in one hour because this is a normal finding c. Apply heat to the client's left leg to increase the circulation d. Notify the health care provider of this abnormal finding

d. Notify the health care provider of this abnormal finding

A 25-year-old woman comes to the emergency department with a sudden fever of 38.3 C and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: a. Endometriosis b. Uterine fibroids c. Ectopic pregnancy d. Pelvic Inflammatory disease

d. Pelvic inflammatory disease

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region b. Inspect and palpate in the epigastric region c. Auscultate and percuss in the inguinal region d. Percuss and palpate the midline area above the suprapubic bone

d. Percuss and palpate the midline area above the suprapubic bone

The nurse on a telemetry unit is performing morning assessments on the clients. Upon auscultation of an adult client's heart sounds, the nurse notes a scratchy, high-pitched sandpaper sound. How should the nurse document this sound? a. Benign heart murmur b. Inspiratory stridor c. Midsystolic click d. Pericardial friction rub

d. Pericardial friction rub

During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a: a. Rectal polyp b. Pruritis ani c. Carcinoma d. Pilondial cyst

d. Pilondial cyst

The nurse is providing patient teaching about an erectile dysfunction drug. One of the drugs potential side effects is prolonged, painful erections of the penis without sexual satisfaction, which is known as: a. Orchitis b. Stricture c. Phimosis d. Priapism

d. Priapism

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decrease 20 mmHg during inspiration and increased with expiration. What do these findings indicate? a. Pulus alternans b. Pulsus bisferiens c. Pulsus bigeminus d. Pulsus paradoxus

d. Pulsus paradoxus

A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as: a. Deep somatic b. Visceral c. Cutaneous d. Referred

d. Referred

A patient is unable to read even the largest letters on the Snellen chart. What should the nurse do next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again d. Shorten the distance between the patient and the chart until the letters are seen and record that distance.

d. Shorten the distance between the patient and the chart until the letters are seen and record that distance.

The nurse is performing a breast examination. Which if these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination. Have the woman: a. Bend over and touch her toes b. Lie down on her left side and notice any retraction c. Shift from a supine position to a standing position, and note any lag or retraction d. Slowly lift her arms above her head, and note any retraction or lag in movement

d. Slowly lift her arms above her head, and note any retraction or lag in movement

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the should, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

d. Spastic hemiparesis

Which vein(s) is (are) responsible for most of the venous return in the arm? a. Deep b. Ulnar c. Subclavian d. Superficial

d. Superficial

The nurse is conducting an eye-screening clinic at a daycare centre. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye" and will: a. Examine the external structures of the eye b. Assess visual acuity with the Snellen eye chart c. Assess the child's visual fields with the confrontation test d. Test for strabismus by performing the corneal light reflex

d. Test for strabismus by performing the corneal light reflex

A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall and now I have noticed that she has his spot that is soft on the top of her head. Is there something terribly wrong?" The nurses best response would be: a. Perhaps that could be a result of your dietary intake during pregnancy b. Your baby may have craniosynostosis, a disease of the structures of the brain c. That soft spot may be an indication of cretinism or congenital hypothyroidism d. That soft spot is normal, and actually allows for growth of the brain during the first year of your baby's life

d. That soft spot is normal, and actually allows for growth of the brain during the first year of your baby's life

The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? a. There are no sensory nerves in the anal canal or rectum b. The rectum is about 8 cm long c. Above the anal canal, the rectum turns anteriorly d. The anorectal junction cannot be palpated

d. The anorectal junction cannot be palpated

The nurse is reviewing the anatomy and physiological functioning of the heart. Which statement best describes what is meant by atrial kick? a. The atria contract during systole and attempt to push against closed valves b. Contraction of the atria at the beginning of diastole can be felt as a palpitation c. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole.d d. The atria contract toward the end of diastole and push the remaining blood into the ventricles

d. The atria contract toward the end of diastole and push the remaining blood into the ventricles

A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend who just died from cancer of the prostate. He is concerned this will happen to him. How should the nurse respond? a. The swelling in your prostate is only temporary and will go away b. We will treat you with chemotherapy so we can control the cancer c. It would be very unusual for a man your age to have cancer of the prostate. d. The enlargement of your prostate is caused by hormonal changes, and not cancer.

d. The enlargement of your prostate is caused by hormonal changes, and not cancer.

A patient comes into the ED after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. The nurse recognizes that the patient may have a corneal abrasion when: a. The corneas are smooth and clear b. The lens behind the cornea is opaque c. There are areas of bleeding across the cornea d. There is a shattered look to the light rays reflected off the cornea

d. There is a shattered look to the light rays reflected off the cornea

The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. Painful vesicle inside the cheek for 2 days b. Presence of moist, nontender Stensens ducts c. Stippled gingival margins that snugly adhere to the teeth d. Ulceration on the side of the tongue with rolled edges

d. Ulceration on the side of the tongue with rolled edges

During an assessment, the nurse notes that the patient's apical impulse is laterally displaced and is palpable over a wide area. This finding indicates: a. Systemic hypertension b. Pulmonic hypertension c. Pressure overload, as in aortic stenosis d. Volume overload, as in heart failure

d. Volume overload, as in heart failure

During the cardiac auscultation, the nurse hears a sound immediately occurring after S2 at the second left intercostal space. To further assess this sound, what should the nurse do? a. Have the patient turn to the left side while the nurse listens with the bell of the stethoscope b. Ask the patient to hold his or her breath while the nurse listens again c. No further assessment is needed because the nurse knows this sound is S3 d. Watch the patient's respirations while listening for the effect of breathing on the sound

d. Watch the patient's respirations while listening for the effect of breathing on the sound

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. Your breast milk is immediately present after the delivery of your baby b. Breast milk is rich in protein and sugars (lactose) but has very little fat c. The colostrum, which is present right after birth, does not contain the same nutrients as breast milk d. You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy

d. You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets really dizzy and feels like she is going to fall over. The nurses best response would be: a. Have you been extremely tired lately? b. You probably just need to drink more liquids c. I'll refer you for a complete neurologic examination d. You need to get up slowly when you've been lying down or sitting

d. You need to get up slowly when you've been lying down or sitting